Phlegmasia Cerulea Dolens: a sudden unexpected death with hypothesis of medical malpractice

Phlegmasia Cerulea Dolens (PCD) is a severe and rare form of venous thrombosis of the lower extremities, caused by a subtotal or complete occlusion of venous outflow by a thrombus. PCD should be considered a real medical emergency; complications include necrosis and gangrene of the affected limb, amputation, massive pulmonary embolism and, in extreme cases, the death of the patient. Case Report. A 63-years-old man was admitted to the Emergency room with localized pain on the right calf, hyperthermia, cold sweating and vomiting episodes. Five days prior he developed flu-like symptoms, joint pain and cold sensation unresponsive to treatment. Ultrasound examination showed a deep venous thrombosis of the lower right limb with partial occlusion of common iliac and femoral veins. The patient was treated with low molecular weight heparin given twice daily. He began to develop severe hypotension and metabolic acidosis, with tachycardia and atrial fibrillation. Despite the treatment, there was no improvement and he developed severe sinus node dysfunction. He failed to respond to all resuscitative efforts and died. Family members complained Authority, assuming it was a medical error. The clinical-forensic investigation is essential to determine the causes and manner of death and to assess medical responsibility and liability.